GW1--07799_Well Construction - GW1_20231201

MILLI,:CON t
ai�'o� Print Form
1.Well Contractor or lntertnel Use Only
Cameron Basin
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t■eca_WctlCmnc4r Name-- T u nav4518-A
. well meter eationNumber rt. ;) (rrjt�
Agtla Drill Inc. is.5___rciG+siNcffltr■tritianederd. OR INNEAtua
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CompatprName R ° rnue esy MwtettA[
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2 Well Construction Permit#: ,p1 3 i it:1IQHp,11 CASIlVG OR TVBUIC(1a f Ltr1 a#4 cabk xeil tnicdion pe is(Le UIC 4:Amu Yarter oe PROM TO ° t111 1TWCX1MATZRL
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3.wen Use(check well rue): _ to
R.
Water Supply Well: 17.scREEN —
:� t rural Municipal/PublicRR__-- To WAMBTI:R SIA7r:17R
k al Geothermal f. f. ie. 'rnrC7Qfgg6 MATERIAL
I � �Supply) BResiciential Water Industrial/CommercialSupply(single)
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III 0Ressdahtinl Water Supply(shared)lla GROVE
a :on
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Non-Water Supply wen: FROM , TO MATT AL as rammCeoo&AMOvxr
Mtxritoti,_ Recovery G, R ? 2 • n,j2.i
Injection Well: ft.
a Aquifer Recharge DGmundwaterRemediation ft. 't
it • - Sttntageand Recovery °SalinityRanie 19.SAND/GRAVELPACICOfsindiaiWe)
i . Ter Test PROM To MAn Qi tL tutu ACSM®e r n oo
OStotmwater Drainage R. ft.
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-'mental Technology °Subsidence Control
�'Geothermal(Closed Loop) O-r ft. ft.
racer 20.DRILLING LOG(attach addttlnIi sheets if npwary)
Geothermal(Heating/Cooling FRO"/Ret Return) Other(explain under#21 Remarks) F To t�cITIOR(eshe tune.®,"Iim' c ems,Van am.ew)
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4.Date Well(s)Completed: t�/7/13 well m0 R �o �G�r>
I 22� (2.0(.4.
Sa.Well Location: a R.
Fart Name Facility tDg(ifappliabie) ft. ft.
Gs,' (2.. I.- J rug,
Physical Address,Crty,ant Zip R. ft,
C.aS(..-e II 21.REMARKS _
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in dagreeslmisates/seconds or decimal degrees:
(if welt field.one latIlong is auf clam) 22.Certification:
36, 2%(CV tr 79'-2410 w
6.Ig(are)the wells ermanent or (°Temporary Signature of Certified Well CoaRaelor
4(77/7
Tey stgning tMtlarm,I Aaaby ons/J,r Av3 the we/I(s)i+u (uric).22"" wd br accordance
7.Is this a repair to an existing well: ['Yes or Nowith ISA KCAC 02C.0100 wr ISA hCAC 02C.0200!Yell Cansnvclian Siandarde and rho/a
"this is a npalr,fill out knolls,well bodkin informal' explain the nature of the coPY ofthk record bus been proWded to the well owner
papal,under#2!remark:section or ea the back of this form. 23.Site diagram or additional well details:
You may use the back of this pigs;to provide additional well site details or well
S.For Geoprobe/DpT or Closed-Loop Geothermal Wells having the sump
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells CO° " °°details. You may also attach additional pages if necessary.
drilled:
Num iITTA[,QmSTRUcnoria
9.Total well depth below land surface: 3 (f) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths df ddffereat(example-3®206'and 2 166) construction to the following:
10.Static water level below top of casing: v (ft) Division of Water Resources,Information Processing Unit,
limier level is above rosins,use-+^// 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter„ v M.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy o1'this form within 30 days of completion of well
12.Well construction method: Co tar g r,/ . construction to the following:
(Le.auger,rotary.cable,direct pob,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resourcte,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(Epm) ;� Method of test: 1....
7 t;
Q7 24a For Water Supply&Injection Wells: In addition to sending the form to
t theaddress(ea) above, also submit one copy of this form within 30 days of
13b Didafedlon type: Amount: '— completion of well construction to the county health department of the county
where constructed.
North Carolina Deportment of Environmental Quality-Division of Water Resortces Form GW-1 Revised 2-22-2016
r MI War. 4 Asj' t.7-t9 n% .,.ct.&— -